COMPLIANCE INFO_2006-2007 - Laserfiche WebLink

Home Browse Search

SYSTCERTIFICOONEM se se By All Jurisdictions Within the State of California J Authority Cited:Chapter 6.7,MON'Tand Safety Code,Chapter 16,Division 3 Title 23,Califomia Code of Regulations This form must be used to document testing and servicing of monitoring equipment. If more than one monitoring system control panel is installed at the facility,a separate certification or rgoort must be prepared for each monitoring system control parial by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A.General Information Facility Name: ARCO#2133,CC 18022644 City: STOCKTON CA Zip:95209 Site Address: 2908 BENJAMIN HOLT DR. Contact Phone No: 964-0180 Date of Testing/Service: 04/20/2006 Facility Contact Person: MARK Make/Model of Monitoring System:TLS350 Work Order Number: 2242155 B.Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced Tank ID: RUL SLAVE Tar*ID: RUL MASTER X In-Tank Gauging Probe. Madel: MAG X in-Tank Gauging Prole. Model: MAG X Annular Space or Vault Sensor. Madel: 794390-420 Annular Space or Vault Sensor. Model: 794390-420 X Piping Sump/Trench Sensor(s). Model: 794380-208 771 794380-208 AJ Piping SumpfTrench Sensor(s). Model: X Fill Sump Sensor(s). Model: 794380-208 794380-208 F�Sump Sensor(s). Model: Mechanical Line Leak Detector- MedtanicN Line Leak Detector. Model: Electronic Lire Leak Detector. - PLLD Electronic Lire Leak Detector. Madel: Tank OverfHVHigh•Level Sensor. Tank OverfilUtiigh"Level Sensor. Madel: Other(specify equipment type and model in Section E on page 2). Other(specify equipment type and model in Section E on page 2). an I an X In-Tank Gauging Probe. : MAG In-Tank Gauging Probe. Model: X Annular Space or Vault Seng. : 794390-420 Annular Space or vault Sensor. Model: X Piping Sump/Trench Sensor(s). Model: 794380-208 Piping Sumplfrench Sensor(s). Model: X Fill Sump Sensor(s). Madel: 794380 208 Fill Sum Sensor(s). Model: X Mechanical Line Leak Detector. Model: VAPORLESS Mechanics!Line Leak Detector. Model: Electronic Lire Leak Detector. Model: Electronic tine Leak Detector. Model: Tank OverfilMgh-Level Sensor. Model: Tank OvenfillMigh-Level Sensor. Madel: Other(specify equipment tyle and model in Section E on page 2)• Other(specify equipment type and model in Section E on page 2). Dispenser : 1/2 Dispenser ID: 3/4 3q Dispenser Containment sensor(s) Model:794380-208 X Dispenser Containment Sensor(s) Model:794380-208 X1 Shear Valve(s). X Shear Vabe(s) ::]Dispenser Castainment Float(s)and Chain(s). Dispenser Containment Fk)at(s)and Chain(s). Dispenser ID: 5/6 Dispenser ID: 7/8 X1 Dispenser containment sensor(s) Model:794380-208 711 Dispenser Containment Sensors). Mme:794380-208 X Shear Valve(s). 71 Shear Valve(s). Dispenser Containment Float(s)and Chain(s). Dispenser Containment Floats)and Chain(s). Dispenser ID: Dispenser ID: Dispenser Containment Sensor(s) Disperser Contairiment Sensor(s). Model: Shear Valve(s). Shear Valve(s). Disperser Containment Fbnt(s)and Chain(s). Dispenser Containment Floats)and Chain(s). "If the facility contains more tanks or dispensers,copy this form.Include information for every tank and dispenser at the facility. C. Certification I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers'guidelines. Attached to this certification is information(e.g manufacturers'checklists)necessary to verify that this information is correct. and a Site Plan showing the layout of monitoring equipment.For any equipment capable of generating such reports,I have also attached a copy of the(Check all that apply): ®System set-up ®Alarm history report Technician Name(print): DAVID MATHIE Signature: Certification No.: 006-05-1937 License.No.: Testing Company Name:Tanknology Phone No.: (800)8004633 Site Address: 8501 N.MoPac Expressway,suite 400,Austin,TX 78759 Date of Testing/Servicing: 04/20/2006 Monitoring System Certification Page 1 of 3 Based on CA form dated 03/01